Last month I was asked to write an article for The Practising Midwife in which I explored some global perspectives on contraception. Here is an extract from that article.
World population currently stands at more than 6.6 billion, and half of the world’s population is under 25 years old. The United Nations predicts that, if couples average 1.6 children, the world population will peak at 7.7 billion by 2050, and decline to 3.6 billion by 2150 (United Nations 1999). By averaging two children, the world population will rise to 9.4 billion by 2050 and reach 11 billion by the next century before stabilising. By averaging 2.5 children, the world population will increase to 11.2 billion and increase to 27 billion by 2150.
In 1994 the United Nation’s International Conference on Population and Development (the Cairo Conference) identified that population control required an holistic perspective, considering socio-political agendas and economic factors, rather than a focus on contraception alone.
Mortality and morbidityBirth rates today are highest in the poorest regions (UN 2006). At present, average
expectation of life at birth is 63 years in Latin America, 57 years in Asia and only a little over 46 years in Africa, compared with more than 71 years in the developed regions. Although on average fewer than one in 40 children dies before reaching the age of one year in the developed countries, one in 15 dies before reaching one year in Latin America, one in 10 in Asia and one in seven in Africa. Because of major health threats such as AIDS and malnutrition, in some parts of Africa average life expectancy at birth is estimated to be less than 40 years, and one in four children dies before the age of one year. AIDS has changed the sexual health and contraceptive needs of women, and now protection from infection as well as from pregnancy is required.
Every year, around 530,000 women die during pregnancy or in childbirth. Lifetime risk of maternal death is one in six in Afghanistan, one in seven in Niger, one in 13 in Uganda and one in 14 in Ethiopia.In more developed countries this risk is one in 2,500 (WHO 2004). Additionally, each year 3.3 million babies are stillborn, more than 4 million die within 28 days of birth, and another 6.6 million children die before the age of five, the majority from preventable causes. Less than 1 per cent of these deaths occur in the more developed countries.
Women who are in poor health are more likely to give birth to unhealthy babies, and often cannot provide adequate care. Studies in Bangladesh in the 1980s found that when a mother died, her newborn baby had a very small chance of surviving the first year (PAI 2006). The spacing of births therefore has a powerful impact on the chances of a mother and her child’s survival. In less developed countries children spaced less than two years apart are about 2.5 times more likely to die before the age of five than children spaced three to five years apart. Babies of mothers who have pregnancies close together are often born underweight or premature, develop slowly and have an increased risk of childhood diseases (PAI 2006).
Older children surviving their mother’s death are less likely to eat a balanced diet, and girls often leave education very young to care for younger siblings. Young girls who are not in education are more at risk of teenage pregnancy. Teenage girls are less likely to get antenatal care and are at greater risk of birth complications. Girls aged 15 to 19 are twice as likely – and girls under15 five times as likely – to die in childbirth than young women in their twenties (PAI 2006). Young women are also more at risk of developing sexually transmitted infections and HIV/AIDS. Every year, almost half of all new HIV infections and at least onethird of all new sexually transmitted infections occur in women under 25 (Panchaud et al 2000).
Abstinence is often the only form of sex education and contraception available, and coitus interruptus (withdrawal of the penis prior to ejaculation), natural family planning (fertility awareness) and lactational amenorrhoea are still widely used. Their efficacy is low, although better than nothing, and they offer no protection from infection......
Barrier methods such as the male and female condom are more expensive than the traditional methods, but offer good protection from infection when carefully used. They need to be positively and sensitively promoted as there are myths surrounding contraceptive use in many cultures, and inaccuracies are disseminated sometimes for religious and political reasons. Papers have been published to persuade people not to trust condoms, but to abstain in preference, sometimes falsely claiming that condoms let through infection
Contraception provision in remote areas is more complicated as more resources and expertise are required for hormonal methods, diaphragms and IUDs.
Abortion
Approximately 87 million unintended pregnancies occur each year; more than half end in abortion. About 18 million of those abortions are thought to be unsafe. About 68,000 women die from unsafe abortions every year; more suffer serious complications (WHO 2005). Studies show that contraceptive use correlates with a considerable decline in the abortion rate, and a corresponding reduction in abortionrelated deaths (Senlet et al 2001). In Russia between 1998 and 2001, contraceptive usage increased by 74 per cent and the abortion rate declined by 61 per cent (PAI 2005). In Kazakhstan, contraceptive prevalence increased by 50 per cent in the 1990s, and
abortion rates decreased correspondingly (Westoff 2001). Abortion rates in the Czech Republic have fallen from 116,000 per annum in the late 1980s to 27,600 per annum now, as the percentage of Czech women using birth control pills has quadrupled (Henshaw et al 1999). Women needing abortions will often risk unsafe conditions. The provision of legal abortion helps save lives, but does not increase the use of abortion. In many Latin American and African countries where abortion is illegal or severely restricted, abortion rates are higher than in Western Europe where it is legal. In poor countries, women face a higher risk of death from unsafe abortion. For example, in Africa, one in 150 abortions leads to death compared with one in 85,000 in more developed countries (WHO 1998). It is estimated that 350 million women in developing countries lack access to effective contraceptives (Henry J Kaiser Family Foundation 2004). Politicians can have immense control over access to contraception, abortion and sterilisation. Restrictive abortion policies affect poor people more than wealthy because poorer people rely on the public sector for their health needs whereas women who have money can usually pay for an abortion privately and bypass public policy.
Nevertheless, the United States has a contentious policy known by its opponents the ‘Global Gag Rule’ which denies US Family Planning funding to any national or international organisation that supports abortion. Many international governments condemned the restriction as detrimental to women’s health and a breach of the right of citizens to participate in their own democratic political processes. This is seriously restrictive, as most organisations that deal with contraception do refer for abortion on contraceptive failure.
In the UK, abortion is relatively safe. In 2005 a total of 186,400 abortions were performed on residents of England and Wales; 84 per cent of these were funded by the NHS (ONS/DH 2005). Eighty-nine per cent of abortions were carried out at under 13 weeks’ gestation; 67 per cent at under 10 weeks (ONS/DH 2005). Women seeking abortion do so under the Abortion Act (1967) Amended, which requires two registered medical practitioners to be of the opinion that an abortion is justified in the light of their clinical judgement of all the particular circumstances of the individual case.
Empowering women
Modern methods of contraception can empower women to be independent; economically active; live a longer, healthier life; and provide better for a limited number of children, enabling them to have a much better chance of survival (PAI 2006).
Contraception in the hands of women also enables them to make choices independently of their partners whenever necessary; and when domestic abuse prevails in a culture, contraception and access to abortion can be crucial to a woman’s ability to survive and move on. Women who are not pregnant or bringing up small children on the whole are able to engage in uninterrupted work more easily, and in more developed countries make career progress more quickly. However, some women may feel pressured to work because welfare benefits and maternity and paternity leave provision are inadequate. Fertility and contraceptive use and increased autonomy are linked to the education of women in developing countries (Castro 1995, Saleem and Bobak 2005). This link plays an important role in the development of family planning policies in lower-income countries.
Enforced population control
There is evidence at the structural level that
extreme cases of ‘population control’ have forced women to use contraceptives, have abortions or to be sterilised. Incentives and education The population of India is set to rise above 1 billion by 2050, and this has occupied politicians for decades (National Commission on Population 2000). India was the first country in the 1950s to start a National Family Planning Programme, and in the 1970s the role of the Auxiliary Nurse Midwife (ANM) expanded into population control. ANMs had targets to recruit people to take up contraception and sterilisation, and were denied payment if they underachieved. Another method of persuasion employed in India was the use of incentives. The Indian Family Planning Council in the early 1970s recommended an incentive of food to anyone undergoing vasectomy. Female sterilisation was incentivised again in 2000. Opponents criticised the temporary nature of the incentives. A more recent policy in India discourages marriage before the age of 21 because teenage marriage contributes to population growth. India no longer sets targets on contraceptive use or sterilisation but now strives towards better access to healthcare and a focus on female literacy.
Involuntary sterilisation
Involuntary sterilisation has been reported in Eastern Europe since the 1970s, and was again highlighted in the media in 2003 when it was reported that Romani women in Slovakia continue to be subject to violations of their human rights. A three-month study revealed that coerced and forced sterilisation practices continued in Slovakia against Romani women. The New York Center for Reproductive Rights (2003) conducted interviews with more than 230 women in almost 40 Romani settlements throughout eastern Slovakia. They found instances of coerced, forced and suspected sterilisation of Romani women, along with racially discriminatory standards of care including denial of access to medical records (CRLP 2003).
Social change
Human rights and law can be used as instruments for social change. In Colombia, an organisation called Profamilia established a legal service for women to help them secure reproductive and sexual rights. The service addresses abortion services, prevention of sexually transmitted infections, informed consent, emergency contraception and gender-based violence. As a result of this initiative, the Ministry of Health in Colombia changed some policies and guidelines.
Urbanisation and coercion
By the end of this century the majority of the world’s population will be living in urban areas. Urbanisation is an element of the process of modernisation. Some countries manage this well, but others do not – and in these parts of the world it is uncontrolled, accompanied by overcrowding, slums, deterioration of the environment, unemployment and other socio-economic factors.
China is particularly renowned for its very strict one-child policy. The country’s population is expected to increase to 1.6 billion by 2050 (Heilig 1996). The one-child policy was introduced in the late 1970s and claims to have prevented at least 250 million births since 1980 (Zhu 2003). In the early years of the policy, women who were visibly pregnant for a second time were encouraged to have an abortion, even late into the pregnancy. In addition, hundreds of thousands of women have been sterilised.
The one-child policy restricts couples to having one child, unless either is from an ethnic minority or if they are both ‘only children’. With one child, families receive free education and benefits, which are withdrawn if couples have another child, and they face a fine for every additional birth. In most rural areas, a couple may have a second child after a break of several years. It is therefore more common to find couples in the countryside, where 80 per cent of the population live, with a large number of children. Sons are often preferred as they carry on the family name. More than 90 per cent of all aborted fetuses in China are female (Zhu 2003). Some maintain that this policy has led to the killing of female infants. Men are thought to outnumber women in China by more than 60 million – some estimate 100 million (McCurry and Allison 2004).
For the full article and references please click here or email barbara@contraceptioneducation.co.uk
